Role of cyclooxygenase-2 inhibitors in postoperative pain management

COX-2 inhibitors represent a significant therapeutic development because of their improved side-effect profile compared with nonselective NSAIDs [81]. Although the analgesic efficacy of the COX-2 inhibitors is similar to that of nonselective NSAIDs, the use of COX-2 inhibitors in the perioperative period is associated with several potential advantages (Box 1). Because of the lack of antiplatelet effects, the COX-2 inhibitor therapy may be continued throughout the perioperative period thus avoiding an exacerbation of postoperative pain. This may be important because the intensity of preoperative pain has been shown to correlate directly with the severity of postoperative pain and opioid requirements [171]. However, questions remain regarding the use of COX-2 inhibitors, such as the restriction of their use to patients at high risk for complications, the impact on postoperative outcomes [172], adverse events [173], cost effectiveness [174], effectiveness compared with nonselective NSAIDs plus prostaglandin replacement or acid reduction therapy, efficacy compared with and in combination with other analgesics [175], and safety in patients also taking aspirin for platelet inhibition [176,177]. Future studies as well as post-marketing surveillance should provide more information regarding the safety of COX-2-specific inhibitors, particularly in high-risk populations.